Provider Demographics
NPI:1104047844
Name:COULTER, MICHAEL DENNIS (PT)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:DENNIS
Last Name:COULTER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7767 WESTCROFT DRIVE
Mailing Address - Street 2:
Mailing Address - City:SYLVANIA
Mailing Address - State:OH
Mailing Address - Zip Code:43560-1863
Mailing Address - Country:US
Mailing Address - Phone:419-517-4255
Mailing Address - Fax:
Practice Address - Street 1:27064 OAKMEAD DRIVE
Practice Address - Street 2:
Practice Address - City:PERRYSBURG
Practice Address - State:OH
Practice Address - Zip Code:43551-2657
Practice Address - Country:US
Practice Address - Phone:419-874-6957
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT6191225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000272642OtherANTHEM
OH2308185Medicaid
OH341952632-00OtherWORKERS COMP
OH000000272642OtherANTHEM